Why Co-Design Fails in Mental Health

Co-design in mental health has become one of the most influential ideas of the past decade. Across government, research, suicide prevention, and community services, organisations increasingly accept that people with lived and living experience should help shape the systems meant to support them.

It is a welcome shift.

For a long time, decisions were made about people rather than with them, and co-design emerged as a response to that history. It challenged settled assumptions about who counts as an expert, and made room for the knowledge that comes from living through distress, recovery, caregiving, service use, suicide bereavement, discrimination, migration, and navigating systems from the receiving end.

Yet despite how widely it has been adopted, many co-design processes leave the people who take part feeling frustrated, exhausted, or unsure whether their involvement changed anything.

The problem is rarely a lack of goodwill; most organisations genuinely want to do this well. The problem is that co-design is usually judged by participation when it should be judged by influence. Organisations tend to ask how many workshops were held, how many people attended, how diverse the group was, and how many consultations took place. Those questions matter, but they are not the ones that decide whether co-design works.

The questions that decide it are quieter:

• Who held authority?

• Who controlled the resources?

• Who made the final decision?

• What changed because people took part?

These are questions about power. And power is where most co-design processes begin to struggle.

Participation is not the same as influence

A process can be busy with participation while leaving decision-making exactly where it started. People are invited into workshops, listened to with respect, thanked for their contribution, and genuinely welcomed into the conversation. Then, when the decisions that matter are made, authority sits where it always sat. The organisation decides, or the project team, or the funder, or the committee, and the people who offered their experience become observers of the outcome rather than authors of it.

This is why people can leave a co-design process disappointed even when everyone's intentions were good. They were present. Presence and influence are not the same thing.

Co-design often begins after the decisions that matter

The most common version of this is a problem of timing. Many organisations invite lived and living experience in after the funding has been secured, the parameters set, the timeline approved, and the priorities settled. By then the room for influence has already narrowed. Participants are asked to refine an approach rather than to shape its direction, and while the consultation may be sincere and the people in it respected, the decisions that counted have already been made.

That is the difference between being asked to improve a solution and being asked what the solution should be. Meaningful co-design starts while the problem is still being defined. In a fuller co-creation cycle that early stage has a name, co-ideation, and it is the stage most often skipped. Skip it, and everything that follows is refinement of someone else's premise.

The same few voices are asked to carry the work

Many organisations rely on a small group of trusted contributors, and the reasons are understandable: those people bring real expertise, established relationships, and a deep working knowledge of the system. But leaning on the same few, over and over, quietly narrows participation, and no group of individuals, however skilled, can stand in for the full range of lived and living experience.

This is where the gap shows most clearly with multicultural communities. When participation narrows to a familiar few under a tight timeline, multicultural and refugee communities are usually the first left out, because reaching them well takes more time, more trust, and language and cultural work that a compressed process rarely allows for. And when one person from a multicultural background is brought in, their presence is often treated as covering "the multicultural perspective", as though a single contributor could represent the enormous differences of language, faith, generation, migration pathway, and visa circumstance that sit inside that word.

The answer is not to exclude experienced contributors. It is to keep widening the pathways, so that a healthy co-design ecosystem keeps developing new voices and new leaders rather than drawing repeatedly on the same ones.

Representation is not the same as leadership

Mental health systems have grown comfortable with representation. Leadership is still the harder thing. Representation means lived and living experience is in the room; leadership means lived and living experience changes what the room decides. Someone can sit on a committee without holding authority, contribute expertise without shaping the decision, and be consulted at length without influencing what happens next. The presence of lived and living experience should never be read, on its own, as proof of its influence. Real influence is visible in the things that actually move: decisions, priorities, resources, and who is held accountable.

Accountability is what gives co-design its credibility

The most overlooked stage of co-design is the one that comes after the workshops end. People give their time, their expertise, their energy, and often their most personal experiences, and they are owed an account of what their contribution did. Too often that account never arrives. Organisations do not come back to say what was heard, what changed, what could not change, and why the decisions were made as they were. Without that, trust erodes, and people draw the reasonable conclusion that their involvement was symbolic.

Accountability does not mean adopting every recommendation. It means being able to show how the decision was reached and how people's contributions shaped it. This is also where treating co-design as a single event, rather than as one stage of a cycle, does the most damage. In the co-creation framework developed by Pearce and colleagues (2020), design sits alongside co-ideation, co-implementation, and co-evaluation as shared stages; in my own practice I add a fifth, co-dissemination, the work of getting what was made back out into communities, policy, and practice.

Co-design fails most reliably when it is lifted out of that cycle and treated as the whole of it: people are invited to the design stage and then handed back out of the room before implementation, evaluation, and rollout, which is precisely where authority lives.

The question beneath co-design

At its best, co-design is less a methodology than a commitment to share influence. That commitment shows in concrete things: involving people early, building participation pathways that are culturally responsive, widening who contributes, making decision-making visible, and staying accountable for what follows. Underneath all of it sits the willingness to look honestly at power. Who has authority?

Who controls the resources?

Who makes the decision?

Who holds the pen?

Those questions tell you more about the quality of a co-design process than any participation metric ever will. The future of co-design will not be settled by how many people are consulted. It will be settled by how willing organisations are to build structures where lived and living experience genuinely shapes what happens next. The question was never whether people were invited into the room. It is whether their being there changed who held influence over the outcome.

Meaningful co-design is not measured by participation alone. It is measured by what changes afterwards.

Many organisations recognise these patterns but are unsure where to start, whether they are designing something new, reviewing a co-design process that has not delivered what they hoped, or strengthening lived and living experience leadership so that participation is meaningful, culturally responsive, and sustainable. If that is the work in front of you, LEXs can help you understand the problem clearly enough to choose the right response. Read how this support works, and start a conversation, on the LEXs consultancy page.